Behavioral and psychosocial factors of quality of life among adult people living with HIV on Highly Active Antiretroviral Therapy, in public hospitals of Southwest Ethiopia

Despite the availability of Highly Active Antiretroviral Therapy, the quality of life (QOL) of People Living with HIV/AIDS (PLWHIV) has continued to be affected. However, previous studies focused on the magnitude and clinical determinants which lacks behavioral and psychosocial factors of QOL. Thus, this study aimed to identify behavioral and psychosocial determinants of QOL among Adult PLWHIV on HARRT, in Public Hospitals of Jimma Zone, South West, Ethiopia, 2018. A cross-sectional study design was conducted in Public Hospitals of Jimma Zone, Southwest Ethiopia from March 10 to April 10/2018. QOL of was measured using WHOQOL-HIV BREF instrument. A simple random sampling technique was employed to enroll study participants. A pretested interviewer-administered structured questionnaire was used to collect data. Then, data were entered into Epi-Data version 3.1 and analyzed using SPSS version 20. Bivariate and multiple variable logistic regression analyses were also performed. A total of 300 respondents were enrolled into the study yielding a response rate of 97.7%. The majority of respondents were from urban residence and between 35–44 years of age. About 47% of respondents have ever used substances, and 58.3% have obtained social support. Nearly 80% and 26.3% of the study participants were stigmatized and severely depressed. More than half of the study participants had good overall QoL with the highest domain QOL in level of independence and lowest in social relations. Factors associated with poor physical health include being government employee AOR 0.33 95%CI (0.15, 0.69), from private business AOR 0.33 95%CI (0.14, 0.79), being 1st wealth quintile AOR 2.44 95%CI (1.16, 5.14), and not obtaining financial support AOR 4.27 95%CI (1.94, 9.42). Lower wealth index has been associated with almost all domain scores of poor QOL except spiritual domain. More than half of the respondents had good overall QoL with the highest domain score in level of independence and lowest in social relations domain. Several factors have contributed to poor domain QOL of PLWHIV. Therefore, it will become all the most important to develop effective strategies, policies and programs targeting people living with HIV. Emphasis should be given to the socio-economic factors that affect their QOL on HAART. Professional counseling and guidance with life skill packages should be strengthened to cope up with adverse behavioral factors. Finally, psychosocial support should be provided from all responsible bodies.

Reviewer #1: The authors submitted a manuscript reporting a study to determine the association of behavioral and psychosocial factors with the Quality of life among adult people living with HIV on Highly Active Antiretroviral Therapy (HAART) in selected public hospitals of South West Ethiopia. Whilst this is an important topic within the scope of this journal, the authors did not provide adequate scientific justifications for the study design, sample size calculation and stastical analysis. Also, the conclusions drawn from the study were not reflective of the study findings. More importantly, the manuscript was not well written in an acceptable standard English as it contains a lot of syntax errors and incomplete statements that made it difficult to understand or follow the lines of thoughts of the authors. I have highlighlighted some major concerns, while the minor comments were indicated within within the body of the manuscript: Response: We thank you for your valuable comments on the paper. Considering an important topic within the scope of this journal, we have tried to provide adequate scientific justifications for the study design, sample size calculation and stastical analysis. Also, the conclusions drawn from the study were reflective of the study findings along with their respective recommendations. More importantly, the manuscript was tried to write in an acceptable Standard English with the considerable effort to edit. Therefore, we tried to respond to each question line by line.
1. Abstract: Given the title of this manuscript, it would be extremely important for the authors to include the name of the tool they used to assess the Quality of Life of the study participants.
How many of the participants were severely depressed among the cases and the controls? What tool was used to assess the study participants to arrive at this classification?
Response: Thank you very much for your insights and comments on the paper. In the abstract, we have now included the tool used to assess Quality of Life of the study participants. You can refer to line 21. Regarding participants with severe depression, in the earlier manuscript it was found in the result section but not in the abstract.
It was to limit the word count. Now, you can find it in the result section of the abstract in line 28-29 and in line 239-240 of the result section under the heading psychosocial factors. Depression was measured using Beck depression inventory (BDI-13score) by PCA considering its internal consistency and reliability with a (Crombach‗s Alpha 0.935) which is above o.7. It was measured using ordered scale from zero to three where the lower indicates minimal and the higher value indicated severe depression. You can find it in the operational definition under the supporting information files. It was not found for a similar reason to limit the word count in the abstract session.
2. Introduction: HIV/AIDS is no more a fatal illness as it has become a chronic manageable communicable disease, with advent of HAART, even in low-income countries Authors should check the follow recent publications: https://innovation.org/diseases/infectious/hiv-aids/hiv-aids-acute-fatal-disease-chronic-manageablecondition; Response: we thank you for the reference provided. We have incorporated in the updated manuscript at lines 48-50 of the introduction session.
3.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3122586/ 3.Authors should consider using a more recent data on national sero-prevalence of HIV in Ethiopia because the prevalence of 1.1% does not support the claim of Ethiopia being a country with high burden of HIV. Also, the national prevalence cited here was that of 2017. Data presenting the trends of the national prevalence of HIV in Ethiopia may be useful for this context: https://knoema.com/atlas/Ethiopia/HIV-prevalence Response: Thank you for letting us uses the more recent data. It's true that using more recent data can better transfer idea. While we were conducting this research during, we used that reference considered updated/recent data that time. We used USAIDS and PAPFAR, 2017 references. Per spectrum preliminary estimate by PEPFAR, January 2017, adult HIV prevalence in Ethiopia in 2016 was estimated to be 1.1%. There is substantial prevalence variation by region (6.6% in Gambella, 5.0% in Addis Ababa, and 0.7% in Southern Nations, Nationalities and Peoples' (SNNPR) region). The HIV epidemic in Ethiopia is primarily associated with areas of urban concentration (5.1% in cities above 50 thousand compared to 3.1% in smaller cities and 0.6% in rural areas) and proximity to major transport corridors. Those living within five kilometers of a major road have HIV prevalence rates that are fourtimes higher than those who live further away. The two exceptions to this general pattern include Gambella region, a small and sparsely populated region that has the highest regional prevalence in Ethiopia (6.4%) and little distinction between urban and rural prevalence, and development schemes and seasonal migrant destinations that show elevated HIV-related risk behaviors despite not being close to urban areas or major roads. That showed great geographic area differences (with High prevalence in Gambella) with High in urban setting than rural. However, the HIV prevalence have shown decline from 2011 to 2016 EDHS reports. The study was taken place in an area where a high number of PLWHIV boarded with Gambella Region South West Ethiopia that accounts for the highest prevalence in Ethiopia.
In line with this, a high number of travelers crossing the zone from Gambella region in which a large number of refugees and mining workers flee in to these study settings. Therefore, researchers considered these issues to undergo this research. physical, psychological, level of independence, social relationships, environmental domains and spirituality domains. The percentages mean score was calculated for each participant. Then, the mean score of percent mean scores was used as a cut-off to categorize the participants as poor (less than the mean score) and good (greater than or equal to the mean score) prior to the actual data collection tool was provided for data collection. This can be clearly seen in the questionnaire that is attached at the supporting information. Perhaps, this was challenging, however, we succeeded doing so. You can find it in data processing and analysis of tracked changes manuscript and the operational definitions under supporting information files. 6. Authors should support this sentence with appropriate references because ref 31 cited was not a case-control study. It was a cross-sectional hospital based study in Nigeria which has one of the highest burden of HIV in the world, after India and South-Africa. Using the prevalence obtained from a hospital-base cross-sectional study to determine the sample size of case-control study in a setting that is not similar to Nigeria, is not only inappropriate but also illogical.
Response: Thank you for the worthy comment. The sample size was calculated by using the double population proportion approach using statistical EPI info 7.1.1 software package by considering the percent of controls exposed of the psychosocial factor (having less social support) among controls (those with good quality of life) is 12% and among cases(those with poor quality of life) is 27.1% with AOR of 2.73 by considering the following parameters: 95% Confidence Level, 80% power, a case to control ratio of 1:3 accordingly, the final sample size, required was 300 (75 cases and 225 controls Response: thank you. As you rose, we used a tool prepared in English that was translated in to local languages (Afan Oromo and Amharic) then back translated in to English to see the consistency. This translated tool has been used to collect the data. As you rose about the literacy level in the study population, the majority of cases were less than grade 4 and controls were less than grade 8. As a result, we used the translated version using forward and backward translations to get valid data from participants. You can find it in lines from 163-165 of the tracked manuscript.
Meanwhile, the tool has been used else-where in different studies in Ethiopia, including in the study area. It is attached at the supporting information as annex.
8. Authors should provide the justifications of p<0.25 for this study.
Response: Thank you indeed. It is well accepted comment. It is due to technical problem and on binary logistic regression analysis, a variable with P-value of ≤0.25 was used for candidate selection we accepted because candidates. It's corrected in the updated manuscript.
9. The references were not consistently cited. Authors should ensure the referencing styling was consistent; they should also provide missing accessed dated and correct URLs.
Response: Thank you indeed; the references are now consistently updated.

Reviewer #2: PGPH-D-21-00472
Thank you for the opportunity to review this manuscript which describes the behavioral and psychological factors affecting the quality of life of people living with HIV in Ethiopia. Despite the successful implementation of antiretroviral therapy in many countries, PLHIV do face challenges that affect their quality of life, and it is important that the body of science in this area be expanded. Here are my comments to the authors.
In brief, the authors need to justify the need for this study clearly in the introduction section, the design used does not appear appropriate but if the authors want to keep it as a case-control design, then they must justify it based on principle and their study procedures. The results section requires significant improvement, this section must start Introduction 1. Please copy edit and perhaps get an English editor the whole manuscript. There are many instances where an article -A‖ or -The‖ is missing at the start of sentences, where punctuations are missing, and where grammar needs to be revised.
Response: We thank you for advising us to make editions to the writing in English regarding this manuscript. We used -grammarly‖ an-online software to edit the spelling, grammar and language usage. Following that grammarlyonline suggested there were word choice, grammar and punctuation issues, we approached PubSURE a research paper language editing service. Accordingly, we tried to respond by taking the comments by PubSure and left some that were illogical. Regarding use of professional editing, we don't afford to pay the required payment.  Overall, census has been done to come up with the main outcome of the study. Then after, we sent the cases (poor quality of life) and controls (with good quality of life) in to the actual data collection rooms. The main questionnaire was administered to identify risk factors associated with poor quality of life.